The Patient-Driven Payment Model (PDPM) was launched on Oct. 1, 2019, so as of this writing, observers have had ample time to see how it is taking shape. Thus far, the Centers for Medicare and Medicaid Services (CMS) has determined that PDPM has not been budget-neutral compared to the last model, as it was intended to be. PDPM is part of the larger, industry-wide shift toward value-based payment systems that reward providers for delivering high-quality care for people in need. While PDPM now requires more tracking and reporting for long-term care (LTC) providers and skilled nursing facilities (SNFs), particularly in terms of ICD-10 coding, the ultimate goal is providing better patient care.

This new reimbursement system was intended to be budget-neutral while shifting from where we’ve been focused (i.e., on therapy volume) to a focus on the patient’s condition. Currently, there are more CMS financial winners than losers under PDPM—specifically:

• 91% winners
• 8% losers

In October 2019, Medicare rates went up with some help from the non-therapy ancillary (NTA) one-time variable adjustment. The projected rate was $563.00 for October 2019, and the realized reimbursement was $615 per day. We saw a 3% decrease in November 2019 without the one-time variable adjustment. Overall the rates remain up, but organizations are still leaving money on the table in the following areas:

• Swallowing/mechanical diets – are not being coded in section K of the MDS
• SOB/lying flat for COPD – are not being coded in section J of the MDS
• Depression – the PHQ-9 are not being completed per the RAI guidelines in section D of the MDS
• Restorative nursing – two programs at least six days per week are not being performed
• Non-therapy ancillary – diagnosis and conditions are being missed in the medical record and are not coded on the MDS

According to online boards and user groups, MDS coordinators still struggle with the transition. Consider:

• There 150 data points to evaluate on the MDS for PDPM
• They must ensure the MDS Coordinator has the skill set necessary in the new PDPM landscape
• They have a lack of accurate resources at their fingertips
• They still struggle with workload changes
• They don’t have a reliable support system

SNF managers should continue to schedule PDPM trainings, provide current resources and identify outside opportunities whenever available. Examples include:

• MDS Certification class (RAC-CT)
• Networking opportunities
• Webinars
• Available up-to-date coding resources
• Conducting an audit or peer review
• Ensuring all available tech tools are enabled

We also strongly recommend that facilities complete regular in-house audits. It’s critical that you identify your MDS documentation and process gaps before the Centers for Medicare and Medicaid Services (CMS) does. Focus on the areas that have already been identified as targets:

• NTA diagnoses and services with supportive documentation
• Speech therapy comorbidity diagnoses with supportive documentation
• Acute neurologic diagnoses with supportive documentation
• Mechanically altered diets and swallowing disorders
• Depression PHQ-9 score with supportive documentation
• Restorative nursing captured on the MDS with supportive documentation
• Review of Section I for accuracy of I0020B and I8000 items

Additionally, don’t forget about QAPI:

• Add a PDPM audit
• Look for your specific risk areas and address them through the QAPI process
  • Underscoring now is also a risk in the future
  • Swallowing/mechanical diets
  • SOB/lying flat for COPD
  • BIMS scoring on the MDS
  • Depression coding on the MDS
  • Restorative nursing – especially in the lean therapy context
  • Non-therapy ancillary
  • Change in therapy usage
• Implement performance improvement plans (PIPs) as necessary
• Include quality measures (QMs) and outcome measures in the audit process

Keys to PDPM success:

• Get to know your data
  • Internally audit MDS and supportive documentation regularly
  • Contract with an outside consultant for regular audits to ensure accuracy and compliance
  • Collect outcome data to share with your partners
• Focus on MDS competency and training
  • Provide additional training on quality measures and clinical outcomes
  • Provide skills training and competency for nurses and aides to ensure they have the tools they need to care for increasingly acute residents
• Review your software capabilities to ensure maximum optimization and integration
  • Provide additional software training to staff to ensure competency and comfort with job duties
• Continue to build preferred provider/partner networks
• Don’t rely solely on documentation from hospitals
  • Reach out to community physicians for additional resident information
  • Talk to family members to get additional information regarding a resident’s conditions
  • Update pre-admission/admission documentation to look for NTA
  • Ensure accurate and complete medication reconciliation

The past nine months have been a time for learning for providers, as well as for CMS. As both parties continue learning, many more changes will occur along the way. Continued education and access to the latest resources will increase your ongoing success with Medicare reimbursement.

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