PDPM Resource Center
At Stein & Associates, we understand the importance of the relationship between our therapy company and the facilities that we are serving. We studied the Patient Driven Payment Model (PDPM) and made the changes needed to ensure we continued to deliver the highest clinical outcomes for residents while also being mindful of the financial impacts to the facilities. More than ever, the importance of a true inter-disciplinary team is needed to ensure all parties meet their respective goals.
PDPM went into effect October 1st, 2019. This new reimbursement model impacts the way services are managed and delivered, and Stein & Associates is here to help you better understand this new payment system. As always, our top priority will be to treat your residents with the highest quality rehab available, and we will not let the reimbursement model impact that goal negatively.
PDPM is primarily driven by a patient's diagnosis, rather than the amount of therapy provided to determine the Medicare payment. This new case-mix payment model replaced the Resource Utilization Group (RUG) system that was used since 1998.
Stein & Associates is staying ahead of the curve. We’ve developed tools to help project the impact on your facility. In the meantime, we've listed some of the key CMS tools to help you better understand PDPM.
SNF PDPM Technical Report
The main purpose of this report is to give a thorough comparison of the proposed PDPM model to the current RUGs payment model. As you will read in the report, therapy is still a main component of the new plan but is not measured strictly by the amount of therapy provided. The positive aspect of this is that facilities will be compensated for the non-therapy ancillary and clinical care they are providing to their residents.
SNF PDPM Classification Walkthrough
The purpose of this Patient-Driven Payment Model (PDPM) calculation worksheet is to illustrate how a resident is classified for payment purposes and how per diem payment is calculated under PDPM. This document is a draft worksheet that is intended to aid stakeholders in their review of the FY 2019 SNF PPS Notice of Proposed Rulemaking (CMS-1696-P) (NPRM) and in the development of comments on the NPRM. We have carefully reviewed the worksheet to ensure that it represents the resident classification logic presented in the NPRM and accompanying Technical Report.
In the PDPM, there are five case-mix adjusted components: Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Non-Therapy Ancillary (NTA), and Nursing. Each resident is to be classified into one and only one group for each of the five case-mix adjusted components. In other words, each resident is classified into a PT group, an OT group, an SLP group, an NTA group, and a nursing group. For each of the case-mix adjusted components, there are a number of groups to which a resident may be assigned, based on the relevant MDS 3.0 data for that component. There are 16 PT groups, 16 OT groups, 12 SLP groups, 6 NTA groups, and 25 nursing groups. As opposed to RUG-IV, in which a resident’s classification into a single group determines the case-mix indexes and per-diem rates for all case-mix adjusted components, PDPM classifies residents into a separate group for each of the case-mix adjusted components, which each have their own associated case-mix indexes and per diem rates. Additionally, PDPM applies variable per diem payment adjustments to three components, PT, OT, and NTA, to account for changes in resource use over a stay. The adjusted PT, OT, and NTA per diem rates are then added together with the unadjusted SLP and nursing component rates and the non-case-mix component, as is done under RUG-IV, to determine the full per diem rate for a given resident.
SNF PDPM Grouper Tool
The purpose of the grouper tool Excel file is to help users understand how certain items on the Minimum Data Set, Version 3.0 (MDS 3.0) and the proposed payment grouping parameters, which are part of the proposed PDPM, would be used to determine case-mix assignments that are part of the payment calculation under the Skilled Nursing Facility Prospective Payment System (SNF PPS). After the rulemaking process is complete, if CMS finalizes the implementation of the proposed PDPM for FY 2020, CMS would provide official grouper software.
After you download the .zip file and attached spreadsheets, be sure to read the PDF Grouper Tool Help sheet for more detailed instructions on how to use the file. As the disclaimer states, this is a tool that will give facilities a rough idea of how residents will be classified under the new payment structure.
Frequently Asked Questions
The American Health Care Association has compiled a list of the most frequently asked questions regarding PDPM. As they update this list, we will also update this section of our resource center.
These FAQs are generally updated bi-weekly and address common PDPM questions submitted by AHCA members. The responses are developed by AHCA staff based upon published Centers for Medicare and Medicaid Services (CMS) policy and guidance materials or CMS direct responses to specific questions not currently addressed in such materials. If you are unable to locate an answer to a question you have in this document, please submit the question to AHCA’s PDPM mailbox at firstname.lastname@example.org.
Rehab Management Solutions PDPM Calculator
The purpose of this tool is to give the user both an estimated per diem reimbursement from each Medicare Part A resident as well as assist in educating the user as to how the residents will be classified in each category. As you enter the different criteria based on the information about the resident you will be able to see how each item impacts reimbursement for the facility.
Understand, this is only intended to be used to give you an ESTIMATE on the reimbursement and it could change as the PDPM structure is finalized by CMS. There will be some additional "add-on's" that are not calculated by this tool, but will be calculated by the PRICER software, which the CMS uses to determine the appropriate per diem payment.