​Updated Oct. 8, 2019

On Oct. 1, the Patient-Driven Payment Model (PDPM) goes live—no delay. At this point, skilled nursing facilities (SNFs) should have assessed, tested, and made improvements in frontline staff preparedness and systems readiness having used real-time drills on a variety of PDPM-critical functions. Ideally, they should have completed two key steps in September or earlier.

Beta Test Information Technology Functions. PDPM is a complex system that requires a far more detailed collection of patient clinical information and diagnoses than under the soon-to-be-gone Resource Utilization Group (RUG IV) system.

First, SNFs should have requested patient classification simulations and compared those simulations with the outcomes from manual classifications conducted on the same patients but by clinicians.

Second, SNFs should have assessed medical information storage and how new PDPM clinical information is collected and used to keep the care plan current.

Third, assessing how Minimum Data Set (MDS) information flows to billing offices is critical. With 188 MDS items driving payment, and several requiring ICD-10 codes, communication between clinical systems and billing systems is essential.

Review PDPM Transitional Interim Payment Assessments (IPA) Capacity. During October, SNFs must convert all Part A fee-for-service patients to PDPM using a Transitional IPA. Converting all Part A patients to PDPM on one day, or handful of days, likely will be overwhelming and result in errors and payment problems. Finally, SNFs also should have a schedule for Transitional IPAs so the assessments are not all clustered around a handful of days.

What’s Important

For October, SNFs thoroughly should understand: 

1. Time Needed for PDPM Initial Medicare Assessments (IMAs). Beginning on Oct. 1, all new Part A admissions will be assessed using an IMA. SNFs’ admissions teams must set the ARD (A2300) for Days 1 through 8 of the Part A SNF-covered stay. The IMA must be completed within 14 days after the ARD (ARD + 14 days)—ideally earlier if possible and appropriate.  SNFs should know  their IMA completion capacity. If IMAs are taking longer, restructuring your policies and procedures is essential. Failure to submit an IMA within the window results in defaulting to the lowest-paying Case-Mix Groups.

2. Practice IPA Policies and Procedures. IPAs are the optional assessments to adjust Case-Mix Group assignment. IPAs will be conducted for patients once they have transitioned to PDPM if they were in a SNF during September and for any new Part A admissions on or after Oct. 1.

While an IPA policy is optional, AHCA believes it is best practice to adopt such a policy. Having an IPA policy will prevent SNFs from missing needed care plan adjustments and provide policies and procedures for collecting needed medical documentation to support Case-Mix Group changes.

Again, at this point, your SNF should be practicing your IPA policy and procedures.

3. Interrupted Stay Policy Scenarios Assessed and Discharge Assessment Plans are Clear. The Interrupted Stay policy concept is new to SNFs. At this point, SNFs should be ready to handle interrupted stays.

For example, SNFs have policies and tracking processes for an interrupted stay for less than three days and returning from home to the SNF, returning from the hospital to the SNF, or from other post-acute care provider settings.

Additionally, SNF to SNF interrupted stay policies and procedures should be in place. SNF to SNF transfers are considered new stays. So, SNFs should have plans to collect all needed information for an Initial Medicare Assessment. Addtionally, SNF admissions staff should know how to handle interrupted stays that are greater than three days.

Finally, from a revenue projection perspective, SNFs should treat October as an atypical month. Because the Transitional IPAs are the only time an IPA will reset the components variable per diem to day one, SNFs likely will experience higher revenue in October than in subsequent months. December likely will be the first month of more stable, typical PDPM revenue for SNFs. 

Protect Your Bottom Line and Resident Care

AHCA and the American Health Information Management Association are offering two targeted online trainings for PDPM:

1. AHCA/AHIMA ICD-10 Training for PDPM—Coder
Who: billing staff, MDS staff, nursing and therapy staff
Sign up online: ahcancal.org/icd10pdpmcoder

2. AHCA/AHIMA ICD-10 Training for PDPM—Non-Coder
Who: Administrators, DONs, and management staff
Sign up online: ahcancal.org/icd10pdpmnoncoder

Check it out today!

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