Patient Characteristics & Success with PDPM

Thoughtware Alert Published: Aug 18, 2020
Healthcare Event

The Patient-Driven Payment Model (PDPM) went into effect on October 1, 2019. This payment model is built using patient characteristics, diagnoses, and nursing services, and also includes cognitive deficits as well as function scores to calculate a Health Insurance Prospective Payment System (HIPPS) code that is used for billing the claim. With the numerous services, diagnoses, conditions, and other items that impact payment, it’s critical that Minimum Data Set (MDS) personnel develop a consistent process for gathering information. Holding a daily “Medicare Huddle” during the information collection phase can help increase communication and produce better MDS completion outcomes.

The initial step for PDPM is that the Medicare team chooses a primary diagnosis for the skilled stay. This diagnosis must map to one of 10 clinical categories under PDPM. CMS has developed a “mapping tool,” which is available on its website; many software vendors have mirrored this tool in the software programs used for skilled nursing facilities (SNF). Once the primary reason for skilled care is identified, it’s just as important that the Medicare team identifies all diagnoses that were active in the past seven days and continue to affect each patient’s current care needs.

With PDPM there are four components that drive reimbursement. The physical therapy/occupational therapy (PT/OT) component is determined based on the primary diagnosis for the skilled stay in combination with the function score calculated by information collected in the first three days of the stay and entered into section GG of the five-day MDS. The speech-language pathology (SLP) component is determined based on the patient’s cognitive function as determined by either the Brief Interview for Mental Status (BIMS) interview or the staff assessment. A patient is determined to have cognitive issues if the BIMS score is 12 or less. This is an SLP condition. There also are 12 comorbidities that affect the SLP component. Finally, the SLP component is affected by mechanically altered diets or swallowing issues captured in section K of the MDS. The nursing component uses the same diagnoses, skilled services, and treatments that the Resource Utilization Group (RUG) payment model used. In addition to these, there is a nursing function score that’s determined by the information collected during the first three days of the stay and entered into section GG of the five-day MDS. The non-therapy ancillary (NTA) component is based on a point system. Diagnoses, conditions, and services are assigned a point value and the total number of points captured on the MDS determines the NTA case mix group.

Having a systematic process to collect and share information across the Medicare team is important to PDPM success. We recommend a morning Medicare Huddle that provides for an information exchange during the first three days of each patient’s skilled stay. This also is the time when MDS personnel are collecting information from the hospital documentation provided during the admission process. BKD has developed a tool to assist SNFs with systematic information collection that may help increase MDS accuracy—and appropriate reimbursement.

Please reach out to your BKD Trusted Advisor™ or submit the Contact Us form below for additional information or to set up education for your Medicare team.

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