As skilled nursing facilities (SNFs) prepare for the transition to the new Medicare Part A reimbursement system, Patient-Driven Payment Model (PDPM), understanding what is not changing may be as important to appropriate care and reimbursement success as insight into the new requirements.

The Name

The first unchanged element appears within the payment model’s name. Skilled Nursing Facility Prospective Payment System (SNF PPS) refers to the “extended care services” furnished to an inpatient of a SNF. Since July 1998, SNFs are not paid on a reasonable cost basis, but based on a PPS, in which payment rates are adjusted for case-mix and wages within a geographic area.

Even with the introduction of the PDPM component, the prospective payment system premise remains the same within SNF PPS PDPM. Payment rates for skilled services will still be determined before those services are provided.

Payments are on a per diem basis, covering days of the resident’s stay in the facility, as long as the individual remains in need of “skilled” care. For Medicare to pay for skilled services provided to the resident, the facility must also complete a Minimum Data Set (MDS). 

MDS Assessments

PDPM does not change the MDS assessment process, and the first required Medicare assessment is still the five-day assessment. The assessment reference date (ARD) window remains days one to eight, and the MDS still must be completed within 14 days after the ARD.

What does change, beginning Oct. 1, 2019, is that in PDPM, the five-day assessment can possibly set the payment rate for the entire stay. That difference increases the critical nature of the five-day assessment.
Another part of the assessment regulations related to the MDS that will not change is the Omnibus Budget Reconciliation Act of 1987 (OBRA) MDS requirements. This means a facility must continue to complete the Entry and Death in facility records; Admission, Quarterly, and Annual Assessments; Significant Change in Status Assessments; Significant Correction to a Prior Comprehensive Assessment; Significant Correction to a Prior Quarterly Assessment; and OBRA Discharge Assessments (both return anticipated and return not anticipated).

All requirements for setting the ARD, timing for completion, and submission remain unchanged.  

Technical  Requirements

Under PDPM, the technical requirements for Medicare Part A coverage have not changed:
  • The prospective resident must have Medicare Part A coverage with days available in their benefit period.
  • The individual must have been an inpatient of a hospital for a medically necessary stay for at least three consecutive calendar days (midnights). Days in observation or the emergency room do not count.
  • The beneficiary must be admitted to a Medicare-certified bed within 30 days of the qualifying Part A stay. The transfer and admission to the SNF can be from the beneficiary’s home, assisted living facility, or a non-skilled stay in a nursing facility. The day of discharge from the hospital is not counted in the 30 days.
  • The beneficiary must require skilled care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary was previously treated in the hospital. Remember that the applicable hospital condition need not have been the principal diagnosis that precipitated the hospital admission, but any condition present during the qualifying hospital stay.

Requirements for a Skilled Level of Care

Other factors needed to establish eligibility for skilled coverage remain in place. These include:
  • Services are ordered by the physician;
  • The resident requires daily  skilled services:
—Five days or greater per week for rehabilitation services;
—Seven days per week for nursing services; or
—Six days per week for skilled restorative programming (with a word of caution that, when skilled services are based on a skilled restorative program, medical evidence documentation must justify the services, which generally are only a few weeks in duration);
  • As a practical matter, considering availability and feasibility, the daily skilled services must be provided as an inpatient in a SNF; and
  • The services delivered must be reasonable and necessary for treatment of the resident’s illness or injury.

Physician Certification and Recertifications

One of the most important requirements for skilled services to survive Medicare reviewer scrutiny is the need for physician certifications and recertifications. Documentation must meet Medicare’s signature requirements. If Medicare reviewers are unable to verify a signature, the Medicare administrative contractors are to deny the claim.

For the initial certification, there is no requirement for a specific form, but the physician must certify that the skilled care is needed on a continuing basis because of the resident’s need for skilled nursing or rehabilitative care. 

This certification may appear anywhere in the medical record, a form, or notes, but the routine admission order to the SNF is not sufficient for certification.

For recertifications, the record must document the need for continued extended care services, the estimated time the resident needs to remain in the facility, any plans for home care, and that the need for continued SNF care is for the same condition(s) for which the resident received inpatient hospital services.
What is often forgotten is that the physician does not have to be present to sign the certification or recertification; faxed signatures are acceptable. 

Timing of Certifications

Certifications must be obtained at the time of admission or as soon thereafter as practical. The first recertification must be on or before day 14 of the Medicare stay, and each recertification after that must be at intervals not exceeding 30 days from the last recertification. The timing of 30 days is based on the physician’s signature for the designated recertification beyond the 14th day.

If a resident is admitted (or readmitted) directly to the SNF from a qualifying hospital stay, the resident can be considered to meet the level of care requirements, up to and including the ARD for the five-day assessment, when correctly assigned to one of the designated case-mix groups. Although the case-mix groups have been updated for PDPM, this provision will remain in place.

Skilled Daily Services

As described in the Medicare Benefit Policy Manual, Chapter 8, section 30.2, the examples and guidance for skilled nursing and skilled rehabilitation services have not changed. The task with each new admission or readmission is to determine if the service is skilled.

Section 30.2.2 says, “If the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel, the service is a skilled service.” The examples of direct skilled nursing services and indirect skilled services remain unchanged.

Facility staff are working hard to learn the ins and outs of PDPM, but within that learning curve is good news: There are many Medicare regulations that are not changing. ■
Jane Belt, MS, RN, RAC-MT, QCP, is curriculum development specialist at the American Association of Post-Acute Care Nursing.