PDPM (Patient Driven Payment Model) Medicare payment system began 10/1/2019 followed closely by the onset of the COVID-19 public health emergency. Skilled nursing facilities did not have time to become fluent with the new payment system due to the onset of the PHE. This presentation will focus on the nursing and NTA (Non-Therapy Ancillary) components of PDPM. The Medicare teams were not in the practice of focusing on the nursing component qualifiers under the RUG IV payment system, because the therapy RUGs were the payer more than 95% of the time. Medicare teams must become fluent in the nursing component items to ensure Assessment Reference dates are set to capture those services and to keep these items in mind daily when reviewing Medicare coverage so that opportunities to improve payments with an Interim Payment Assessment (IPA) are not missed. The nursing component is the highest paying PDPM component. The functional levels obtained through the Section GG assessments impact the nursing component payment along with the PHQ9 resident interview for mood. The timeframe for assessing the resident functional abilities is limited to the first 3 days of the Medicare A stay when completing a 5-day PPS MDS and on the ARD and the 2 days prior to the ARD of an Interim Payment Assessment. The Functional scoring assessment process is expected to be interdisciplinary. This means there should be collaboration between nursing and therapy to determine the residents’ usual function for each of the GG functional items.
The Non-Therapy Ancillary payment component is new with PDPM. The opportunity to report diagnoses and services that increase payment for medications, lab studies, and medical supplies is very welcome. This component relies heavily on ICD-10-CM coding from physician documented diagnoses. Ensuring the accurate ICD-10-CM codes are entered on the MDS in Section I is critical to this payment component. The NTA component is the second highest payment component of PDPM and has a variable per diem rate that allows triple payment for the first 3 days of each Medicare A stay. In addition to capturing this information on admission, the NTA component qualifiers should be carefully observed in order to make optimal decisions regarding the opportunity for increased payment by an IPA.
Documentation must be in the medical record to provide support for MDS coding and to support the claim during Medicare reviews. Negative Medicare reviews have occurred related to lack of supporting Section GG assessment documentation and incorrect or unsupported ICD-10-CM coding.
- State the MDS item that can impact the nursing component payment even when only provided prior to admission to the SNF, but within the 7-day look-back from the 5-day PPS ARD.
- List the 3 MDS items that qualify a resident for the Extensive Nursing Service group.
- Explain the impact of the variable per diem rate in the NTA component and how it impacts PDPM payment.
- Report the diagnosis code that provides an 18% add-on to the nursing component when coded on the UB-04 even when not coded on the MDS.
Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC
Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.
Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter & Co. P.C., providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).
- 1.5 credit hours for RNs
- 1.5 credit hours for NABs
This pre-recorded webinar expires on August 19, 2023.