A Hard Stop and Fast Go: RUGs-IV to PDPM Transition

September is here, which means October 1st is less than 30 days away. Transitioning the patients receiving care under Medicare Part A to the PDPM September 30th to October 1st will require the planning and attention of the interdisciplinary team (IDT). Here are some IDT considerations for all Medicare A patients admitted prior to October 1st:

  • Payment for the month of September, regardless of admit date, must be transmitted using the RUGs IV classification system.
  • To receive payment for October 1st and beyond, a Transitional Interim Payment Assessment (IPA) must be completed and have an ARD set no later than October 7, 2019.
  • The facility has the normal transmission time frame of 14 days to submit the transitional IPA. Use this time and plan appropriately!
  • Remember! The patient’s care needs and plans do not change on October 1st. Only payment is changing. A therapy recertification or re-evaluation is not necessary, and the facility care plan is still active.
  • Therapy and nursing will need to complete interim Section GG scoring for the 10 Section GG items that produce the PDPM Function Score.
  • Discuss current caseload and any new admissions to identify all necessary comorbidities, clinical conditions and services, restorative nursing needs, primary reason for skilled admission, and surgical interventions during the most recent hospital stay.
  • Ensure timely communication of admissions for screening and/or completion of a holistic evaluation by therapy.
  • Plan for discharge destination and goals upon admission to allow for predictive length of stay and to identify patient specific education and resource needs.
  • Continue to coordinate care between therapy, nursing, and facility support staff to foster outstanding functional outcomes and safe transitions to the next level of care!

Your partners at Reliant Rehabilitation are here to help with the transition to the PDPM.  The Director of Rehabilitation at your facility has been provided extensive training and is equipped to facilitate therapy and collaborate with the facility through the October 1st transition.  Feel free to reach out to your Reliant partners with any questions or to help you problem solve.  Together, we can make this a smooth transition.

Return to Provider Codes and the Patient Driven Payment Model

ICD-10 Codes and PDPM Mapping

The Centers for Medicare and Medicaid Services (CMS) have identified, categorized, and mapped medical conditions through ICD-10 coding which predict payment for physical therapy, occupational therapy, speech therapy, nursing, and non-therapy ancillary needs.

Physical therapy, occupational therapy, and speech therapy will be categorized based on the primary diagnosis for the SNF stay as coded in item I0020B. This single primary diagnosis will then map to 1 of 10 PDPM clinical categories which directly impacts reimbursement.

Are “return to provider” codes allowed?

Certain codes entered in I0020B (primary reason for skilled stay) will map to “return to provider”. If a “return to provider” code is used in I0020B of the MDS, the claim will be returned for revision of the code entered in I0020B.

The “return to provider” codes include symptom codes that may be used by physical, occupational, and speech therapists as treatment diagnoses on their plans of care.

Examples include but are not limited to: M25.561 pain in right knee, M62.81 muscle weakness (generalized), R13.11 dysphagia – oral phase, R27.9 unspecified lack of coordination, R26.81 unsteadiness on feet, and R41.841 cognitive communication deficit.

Symptom codes do not represent the primary reason for the SNF stay; therefore, they are not appropriate for I0020B. However, they do support the highly specified and individualized treatment provided to the patient by therapy and must be coded by therapy as treatment diagnoses and reflected on the UB04 and other areas of the MDS. This coding ensures a full clinical picture of the patient’s clinical characteristics is provided and ensures the claim is supported in the event additional review is requested.

CMS’ FY 2020 SNF PPS Final Rule Released

Yesterday, the Centers for Medicare and Medicaid Services (CMS) issued the FY 2020 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule, which will take effect on October 1, 2019. 

This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2020. CMS has also made minor revisions to the regulation text to reflect the revised assessment schedule under the Patient Driven Payment Model (PDPM). Additionally, CMS revised the definition of group therapy under the SNF PPS, and implemented a subregulatory process for updating the code lists ICD-10 used under PDPM. Finally, the final rule updated requirements for the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program.

Below are a few highlights from the final rule: 

  • The federal rates in this final rule reflect an update to the rates that CMS published in the FY 2019 SNF PPS final rule, which reflects the SNF market basket update, as adjusted by the multifactor productivity (MFP) adjustment, for FY 2020.
  • The SNF market basket percentage is 2.4 percent for FY 2020, which is an increase in payments of $851 million compared to FY 2019. This estimated increase is attributable to a 2.8 percent market basket increase factor with a 0.4 percentage point reduction for the multifactor productivity adjustment. This is a decrease from the proposed update of 2.5 percent and $887 million.
  • Effective October 1, 2019, group therapy will be defined as “a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities.”
  • CMS is not finalizing its proposal to expand data collection for SNF QRP quality measures to all SNF residents, regardless of their payer. 
  • CMS is finalizing as proposed, without modification, the process for updating the ICD-10 code mappings and lists associated with PDPM. As proposed, the subregulatory process for updating the ICD-10 codes used under PDPM will take effect beginning with the updates for FY 2020.   
  • The Final Rule updates requirements for the SNF QRP, including the adoption of two Transfer of Health Information quality measures and standardized patient assessment data elements that SNFs would be required to begin reporting with respect to admissions and discharges that occur on or after October 1, 2020. 
  • CMS is finalizing its proposal to exclude baseline nursing home residents from the Discharge to Community Measure.
  • CMS is finalizing its proposal to publicly display the quality measure, Drug Regimen Review Conducted with Follow-Up for Identified Issues, under the SNF Quality Reporting Program.
  • CMS is replacing the terminology for the “5-Day Assessment” with “Initial Medicare Assessment”.

PDPM Part 9: The Role of Therapy in the Nursing and Non- Therapy Ancillary (NTA) Components

In less than 6 months, the long-awaited transition to the Patient Driven Payment Model (PDPM) will occur. By now you’ve probably participated in multiple webinars and on-site meetings regarding the shift to this new payment model. One of the most consistent themes in these trainings is the use of the interdisciplinary team to ensure accuracy with coding on the MDS. While it may be obvious why the therapy team needs to contribute information for the physical therapy, occupational therapy, and speech language pathology components of PDPM, it may be less obvious why their input is crucial to the nursing and non-therapy ancillary components.

The nursing component within PDPM employs the familiar hierarchical classification method for case mix qualification. The most significant change from RUG IV is the removal of Section G and the ADL score from the classification and the introduction of the Section GG function score. The nursing, PT and OT function scores factor in seven of the same GG late loss items. Unlike RUG IV, there is no direct correlation between the function score and the case mix index (CMI). Therefore, a lower function score does not necessarily mean a higher CMI. However, subtle changes in reimbursement for nursing services provided is reflected in PDPM as seen in the use of restorative programming, extensive services, present condition, and physical function.

The non-therapy ancillary component consists of fifty conditions, each assigned a weighted value of 1-8. The weighted value is in direct proportion to pharmaceutical costs associated with that condition. These point values are summed to determine the comorbidity score for the patient. The higher the comorbidity score, the higher the CMI and reimbursement. Additionally, PDPM accounts for higher pharmaceutical costs early in the stay by front loading this CMI at 300% for the first 3 days of the stay. A thorough review of the medical record, full body assessments, and reconciliation of prescriptions to conditions must be completed to ensure all possible comorbidities are captured on the MDS.

The rehabilitation team plays a critical role in identification and accurate coding of clinical characteristics for the resident in relation to the nursing and NTA components. By establishing a foundation of understanding in relation to therapy’s role for each component, as well as fostering clinical skills to conduct holistic, full system evaluations the therapy team will aid in ensuring comorbidities are accurately coded and help identify the appropriateness of restorative programming. The conversations occurring at the interdisciplinary table regarding each new resident will shift from the projected amount of therapy to review of clinical conditions and care to allow for appropriate resources for the projected needs of the resident.

PDPM is in many ways more of a prospective payment system than RUG-IV has ever been. Therefore, with the transition to PDPM, it is more important than ever for administration, nursing, MDS coordinators, and therapy to coordinate together for accurate coding on the MDS. If one piece of the interdisciplinary team is missing, important patient information may fall through the cracks.

While an interim payment assessment is always an option, capturing an accurate picture during the initial assessment ensures the full intention of the PDPM reimbursement methodology is captured for each component including the NTA’s variable per diem rate.

PDPM Part 7: Changes in the Interdisciplinary Team Conversation

From an active diagnosis of endocarditis to an aphasia comorbidity, it is evident more than ever that physical therapists, occupational therapists, and speech language pathologists need to thoroughly review full body systems during evaluation for identification of the patient’s underlying conditions and comorbidities.

Under PDPM these holistic assessments extend beyond the impaired system and will allow the clinicians to bring relevant, meaningful clinical information to the interdisciplinary table. This information will contribute directly to the identification of SLP related comorbidities and the non-therapy ancillary comorbidity score to ensure the patient’s clinical classification is accurate and representative of the potential resource use needs during their stay.

A breakdown in this interdisciplinary collaboration may lead to missed opportunities for proper reimbursement. However, with extensive therapy evaluations and interdisciplinary collaboration, these opportunities won’t slip through the cracks.

Begin exploring how team conversations will change under PDPM and identify areas to improve interdisciplinary communication. Be on the lookout for Reliant resources relevant to interdisciplinary team success.

PDPM Part 6: High Fives, Whys, Collaboration and Communication

Earlier this month, Reliant hosted regional directors for its annual leadership conference in Plano, Tx. The first day, attendees were inspired by Roy Tuscany of the High Fives Foundation. He offered a patient’s perspective for clinicians and presented a call to shift from the “standard protocol” to the “patient protocol.”

Through his personal story and rehabilitation journey he detailed the importance of cultivating hope in our patients and a killer high five. He emphasized it’s not just the control, attitude, and effort of the patient that effects outcomes and recovery, but the clinician’s control, attitude, and effort that ignites success.

Day two opened with keynote Heath Slawner. Heath passionately detailed the importance of claiming and living out purpose. He led the audience through an exercise to evaluate personal reasoning for our daily choices, during which he stated “start with why.” What is your why? Recognizing and embracing the reason we set out to become a clinician, administrator, or other healthcare professional provides perspective. Knowing your company’s why allows for a common culture and approach to executing product delivery.

These speakers offered the perfect complement to the remainder of the conference which focused greatly on planning and preparing for PDPM. This is the sixth installment of the Reliant Reveal PDPM series. Previous articles have focused on the structural frame work of the model, details surrounding function score calculation, strategies for training, and coding success. Within each article, and the education we have created to date, a complementary theme is emerging: the importance of collaboration and communication.

Success under PDPM may be related to contract considerations, amassed resources, and field education; however, longitudinal success- the success that produces outcomes, will be directly impacted by each care professional’s ability to effectively collaborate and communicate for the patient’s care needs.

Facilities should begin moving from the standard protocol of care to an elevated, patient-driven protocol. This protocol will empower the evaluating therapist to collaborate with nursing to ensure comorbidities are accurately and timely identified. Therapists will bring to the table the clinical characteristics to be identified on the MDS, discharge planning notes, and knowledgeable discussions surrounding the clinical reason for admission.

The successful facility under PDPM will have a clearly defined “why” complemented by Reliant’s why: Care Matters. This is the heartbeat of our daily practice, service delivery, communication and collaborative approach to patient care.

Patient Driven Payment Model (PDPM) Updated Wepage

CMS provides a Patient Driven Payment Model (PDPM) web page which houses a variety of resources (comorbidity mapping tools), fact sheets, and a training presentation.

During the open door forum, CMS announced updates to the materials found on the PDPM webpage in response to stakeholder feedback including:

  • The training presentation has been replaced with the National Provider Call from December 2018,
  • The classification walk-through document has been updated, and
  • The FAQ document has been updated.

PDPM Part 5: Quantity to Quality: PDPM Assessment Schedule

Over the years, the burden associated with the current Medicare required assessment schedule has become “just part of the job.” Staffing of the MDS office is largely driven by Medicare part A census because all residents admitting to a facility for a skilled part A stay will receive a 5-day assessment and depending upon their length of stay may also have a 14-day, 30-day, 60-day, and 90-day assessment. Changes in therapy delivery trigger an additional set of required assessments.


CMS has boasted The Patient Driven Payment Model (PDPM) will reduce provider burden by implementing a significantly reduced required assessment schedule outlined as:5-day Scheduled PPS Assessment | Completed days 1-8 | Covers payment for ALL Part A daysPPS Discharge Assessment | Set as Medicare A stay end date. | Does not affect payment.


In addition to all OBRA requirements remaining the same, the Medicare required PPS assessment schedule consists of these two assessments. That’s it. CMS does acknowledge that changes in the resident’s clinical condition may affect resource use; therefore, they have created an optional Medicare assessment: Interim Payment Assessment (IPA) | Date facility chooses | Payment begins same day as ARD.(triggering event)


Read more about the importance of quality in our MDS assessments here.

Patient Driven Payment Model (PDPM) Frequently Asked Questions

CMS provides a Patient Driven Payment Model (PDPM) web page which houses a variety of resources (comorbidity mapping tools), fact sheets, and a training presentation. An additional resource is the 37 page PDPM Frequently Asked Questions document.
This document covers 14 PDPM topics and answers 92 questions as of 1/28/2019. On the December provider call, stakeholders requested revision dates be provided for reviewers to identify the most recent document update and CMS indicated this would be implemented.
As we progress toward PDPM’s implementation date, be sure to reference CMS’ website frequently to ensure up to date information and clarification.

Nursing Facility Case-Mix Payment Changes October 1, 2019

CMS issued an informational bulletin earlier this month notifying providers of changes that will impact states’ payments for Medicaid beneficiaries in the nursing home setting.

The bulletin indicates with the implementation of PDPM in October 2019 a new optional assessment, specific for states that rely on RUG-III and RUG-IV assessment schedule, will be available. The assessment will be active from 10/1/2019 through 9/30/2020, at which time states will have to determine an alternate calculation system for Medicaid payment. Additional detail was provided in the December 11th MLN call. Read full bulletin here.

SNF PPS: New Patient Driven Payment Model Call

On December 11, 2018, CMS hosted a national Medicare Learning Network call which provided a detailed look at the Patient Driven Payment Model (PDPM).

Some specific details are provided in the article above, and additional resources are available at the PDPM webpage.

Reliant is actively following CMS updates and clarification to ensure our resources and training are up to date and accurate. Watch for education opportunities in early 2019! Full audio recording and transcript are now available on the MLN homepage for download.

PDPM Part 4: Information Overload, Time to Review

When PDPM was finalized in July’s final rule, there was no stopping the development of training and resources by those in our industry who make us successful. It’s what educators do, dissect, synthesize and disseminate information. However, PDPM’s outline in the final rule lacked detail in certain areas and created questions in others. Chances are, some of the training and resources you have saved (even CMS’) are now inaccurate or incomplete.

During the Medicare Learning Network call earlier this month many elements of PDPM were clarified and a few were introduced including:

1. Mapping to the PDPM clinical category will come from new items set, I0020B (What’s the main reason this person is being admitted to the SNF?) coupled with possible responses to new item set J2100-J5000 (Surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission).

2. PDPM classification groups designated under administrative presumption including

a. Nursing groups within Extensive Services, Special Care High, Special Care Low, and Clinically Complex,

b. PT and OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO,

c. SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL; and d. NTA highest category of 12+.

3. Revised Health Insurance Prospective Payment System (HIPPS) coding algorithm.

4. Further instruction on the Interim Payment Assessment including use of Interim Section GG column for reporting and look back.

5. Addition of Optional State Assessment for Medicaid determination (Not a Part A PPS assessment).

6. Examples to clarify Interrupted stay policy and group and concurrent calculation.

7. Extensive instruction on RUG-IV and PDPM transition and mandated transitional IPA if patient is receiving skilled part A services prior to 10/1/2019 and continuing.

8. RAI Manual draft expected “early” 2019.

So with all of the PDPM chatter, how do we filter for quality and accuracy? How do we trust the resource we have is accurate and up to date? Here are a few tips for just that:

1. Gather information from multiple sources. Subscribe to industry leaders and state associations for updates. Read the Reliant Reveal and Real Time Memos as they arrive.

2. Take it a step at a time. No one becomes an expert overnight. Start with the clinical component and case mix groups, then move on to ICD-10 coding, or assessment time frames and rules, but be confident in one element before you begin learning the next.

3. Look for cited sources (RAI Manual, CMS material) and revision dates to resource materials. CMS has indicated they will begin time stamping the FAQ documents to indicate revisions made. Resources from other entities should do the same.

4. When possible, go to CMS webpage for clinical and NTA crosswalk information. These references are available in savable zip file format but have been updated at least two times since their initial release in August.

5. If something clicks and suddenly makes sense, write it down. Don’t assume you’ll remember.

6. Ask questions! If a comment or statement does not make sense, ask for clarification and citation.

Your partners in patient care should want to support you in your journey for knowledge and a successful transition to PDPM. Reliant is ready to keep you up to date, answer your questions, and problem solve for strategic success!

ICD-10 Updates!

Last month we proceeded with our series which dives into critical elements of PDPM by looking at ICD-10 coding. Due to updates provided by CMS we will take one more look at ICD-10 processes for PDPM.

During the open door forum on 11/29/2018, CMS validated information on the PDPM webpage indicating a new MDS item set will be active on October 1, 2019 which will guide the clinical category mapping for the resident. According to CMS’ training materials, new item set I0020B “What is the main reason this person is being admitted to the SNF?” allows for the primary SNF diagnosis to be entered when the response to I0020 “Indicate the resident’s primary medical condition category” is identified as 01-13. The training also provides detailed information about the new items for recording the patient’s surgical history using J2100-J5000. (As of 11/29/2018 CMS notes an error on the PDPM webpage resource New MDS Items which records I0020 as I0200).

It’s important to recognize that although this new item set replaces 18000A as the primary diagnosis mapping line, the codes entered in I8000 and identified throughout section I still require critical thinking and accuracy to ensure accurate reimbursement as these areas contribute directly to SLP comorbidities and conditions, nursing conditions and the non-therapy ancillary comorbidity score.

PDPM Patient Classification Fact Sheet

MDS Changes Fact Sheet

SNF Open Door Forum: 11/29/2018

In the last open door forum of the year, CMS provided the following information:

PDPM Webpage is now active. The site provides CMS created fact sheets, FAQ’s, training presentation, and resources specific to PDPM preparation CMS has created as PDPM specific email for questions or clarification needs.

• SNF VBP updates included clarification that providers incentive multipliers are available via CASPER reports. Phase I correction request review is currently in progress. Reconciled corrections will be updated via reports in the CASPER system. The Medicare Administrative Contractor (MAC) will directly apply the incentive percentage when making payment. More information is available on the SNF VBP webpage.

• SNF QRP data now posted on Nursing Home Compare. The next refresh will be in late January. Providers will receive preview reports 30 days prior. CMS directs any questions to the SNF QRP help desk.

• CMS indicated SNF QRP edit 3907 for discharge goal coding will be retired due to stakeholder feedback regarding its relevance; however, edit 3891, warning for discharge coding, will continue.

• CMS reiterated the resources available through the Civil Money Penalty Reinvestment Program (CMPRP). CMPRP is a three-year effort to reduce adverse events, improve staffing quality and improve dementia care in nursing homes.

PDPM Part 3: Function Scores Here, Function Scores There, PT, OT and Nursing Everywhere!

Unless you’ve slept through the second half of 2018, you’re aware this year introduced updates to Section GG (Functional Abilities and Goals) and are at least familiar with the concept that Section GG plays a role in the Patient Driven Payment Model (PDPM). Today, let’s break down exactly how important of a role Section GG it plays in PDPM and the importance of accurate data collection.

Physical Therapy, Occupational Therapy and Nursing case mix groupers will be directly impacted by Section GG scoring and the PDPM Function Score. Read the full article here so when PDPM officially launches, communication is streamlined and your assessment team is confident in their data.

Reliant’s Section GG Flow Chart

Reliant’s Section GG Reference

CMS PDPM Functional Scoring Fact Sheet

PDPM: Qualifying for a Skilled Stay

As promised, each month Reliant will highlight a technical aspect or clinical component of the new Patient Driven Payment Model (PDPM). We believe these discussions will aide in understanding and minimize concerns regarding beneficiaries’ access to care. This month we will start at the beginning, qualifying for a skilled stay.

The criteria for a resident to qualify for a skilled stay has not changed under PDPM . Per the Medicare Benefit Policy Manual, care at the skilled nursing facility level is covered if the following four factors are met:

1. The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel; are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services. Skilled nursing and/or skilled rehabilitation must

a. Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and

b. Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

2. The patient requires these skilled services on a daily basis. Daily basis is defined to be a. “on essentially a 7-days-a-week basis” but clarifies that a beneficiary’s inpatient stay based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week.

3. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)

4. The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

Under PDPM, as long as these four conditions are met, the beneficiary will qualify for a stay in your SNF. A review of skilled services defined (section 30.2) is always beneficial and highlights the continued need for therapy involvement in the beneficiary’s care.

As Reliant partners to prepare for PDPM, steps to evaluate current trends should be taken. Reliant recommends conducting a facility assessment of the current skilled needs within your facility. Evaluating important factors such as what percentage of residents are skilled for nursing only, therapy only, or a combination of the two? Within each category, what is the breakdown of services provided? Analysis of the facility assessment will guide in predicting resource needs and planning under PDPM, as well as lead to a seamless transition with successful outcomes.