The Patient-Driven Payment Model (PDPM) went live Oct. 1, 2019. Skilled nursing facilities (SNFs) should have completed Transitional Interim Payment Assessments (T-IPAs) for patients with dates of service in September and admitting patients using revised PDPM materials and processes for all admissions beginning on Oct. 1, 2019. With T-IPAs completed and PDPM admission experiences gained, focusing on PDPM care planning and discharge is the next step.

Interdisciplinary teams will need to discuss different information related to Medicare Part A beneficiaries than they discussed under the Resource Utilization Group Version IV (RUG IV). RUG IV Medicare meetings tended to focus on therapy progress and delivery, managing the prospective payment system (PPS) assessment schedule, and monitoring for unscheduled Medicare assessments. Under PDPM, the team will need to focus on the holistic care needs of the resident:

1. Early in the stay, the team will want to discuss the primary reason for the SNF stay, known diagnoses and conditions that affect the rate, the resident’s “usual performance” in self-care and mobility activities, and potential diagnoses that should be explored. Then the team should identify the optimal Assessment Reference Date (ARD) for the Five-Day or initial Medicare assessment. 

2. During a stay, the team will want to monitor for the resident’s progress toward their goals for the stay for two important reasons. First, the Centers for Medicare & Medicaid Services (CMS) is using the IMPACT Act Quality Reporting Program (QRP) to assess provider performance under PDPM. Tracking patient process relative to the QRP is a must.

Second, new monitoring protocols will aid with the identification of the need for a treatment modification and, therefore, the possible need for an Interim Payment Assessment (IPA).

3. As the stay approaches conclusion, the team should be focusing on discharge planning and collection of information needed for the SNF Part A PPS Discharge Assessment. New information needed for the assessment includes Section O reporting in the number of therapy minutes by modality.

While on claims, SNFs will need to report interrupted stays. CMS’ Claims, Billing, and Benefits Manual Updates are: a.) Medicare General Information, Eligibility, and Entitlement Manual PDPM update, which contains minor updates to certification guidance; b.) Medicare Benefit Policy Manual PDPM update, which contains minor updates to the SNF benefit period and benefit days sections in chapter 3, as well as major changes to the SNF PPS guidance in Chapter 8; and c.) Medicare Claims Processing Manual PDPM update, which provides substantial updates to the chapter 6 SNF PPS claims processing instructions.

Finally, now that CMS has released the Claims, Billing and Benefits Manual Updates, providers should revise their Triple Check Meetings and forms. Triple Check is the process of evaluating all components of Minimum Data Set coding, billing, and Medicare requirements to ensure that an accurate Medicare claim is submitted.

Under the RUG IV system, much of the Triple Check process evaluated the accuracy of therapy days and minutes reported. Under PDPM, accuracy of clinical information will focus on the conditions and diagnoses that affect the PDPM rate instead of therapy delivery records.

Providers will also have to continue to ensure that technical requirements of skilled coverage have been met, such as verifying a qualifying three-day hospital stay and ensuring that the applicable physician certifications and recertifications have been obtained. They must review any IPA changes and ensure that clinical documentation supports them and also review any Interrupted Stays for the same documentation.
Members of the American Health Care Association (AHCA) requiring PDPM support may email questions to AHCA PDPM Resource Navigators at

Mike Cheek is senior vice president, reimbursement policy, for the American Health Care Association.