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Your PDPM Questions Answered – Part 1: Laying the Foundation

In Part 1: Laying the Foundation, of our PDPM webinar series with Relias’ Senior Analyst for SNF Regulations and Clinical Reimbursements, Ron Orth, RN, CHC, CMAC, we received so many thoughtful questions. So, Ron has taken the time over the past week to respond to the most frequently asked questions about PDPM.

Your Questions About PDPM

Q: Is there any reason we couldn’t do the following: our facility chooses to do a continuous GG assessment (every day from admission onward) and weekly BIMS — in order to be ready to jump on an IPA immediately when identified?

A: This would be up to facility policy.  There is nothing that says this could not be implemented and would provide you the information you need on a continual basis and provide information needed for an IPA assessment, if applicable.


Q: Any word if we need to do a 5-day MDS in September to get paid under RUG-IV then another one by 10/7/19 as an IPA to get paid correctly during the transition?

A:  Yes, since the RUG-IV system will end on September 30th and the PDPM system begin on 10/1, it will be necessary to establish a RUG-IV category to bill for days prior to 10/1 and a PDPM HIPPS code to bill 10/1 and after. CMS has developed a RUG-IV to PDPM transition plan. More detailed information regarding this question will be covered in Part 5.


Q: Any word if we are able to correct an MDS if an MDS is accidently sent with an invalid Diagnosis?

A:  At this time CMS has not proposed any change to the MDS Correction Policy and a modification should be able to be performed to correct any type of errors.


Q: What assessments will be required for Medicare Advantage plans that are paid by RUG?

A:  That will depend on the specific plan. Any questions related to PDPM and assessment requirements will need to be addressed direction to the MA plan. More detailed information regarding this question will be covered in Part 5.


Q: How would a resident qualify for PT, OT or SLP if they aren’t receiving it?

A:  The PDPM will determine the appropriate case mix group (CMG) for PT, OT and SLP based on clinical characteristics such as diagnosis, functional score, co-morbidities, surgical procedures, etc. as identified on the MDS. More detailed information regarding this question is covered in Part 2.


Q: For clarification…It is my understanding that the IPA has to be done if the resident is discharged and out of the building for MORE than 3 days (4 or more).  Is that correct?

A:  No this is not correct, if a resident is gone for more than 3 days, then a new 5-day assessment is required to be completed. This is known as the “Interrupted Stay Policy”. More detailed information regarding this question is covered in Part 5.


Q: When billing, does the Medicare co-pay still exist starting on day 21?

A:  Yes, the PDPM does not change regulations related to 100% coverage for days 1-20 and the daily co-payment beginning on day 21 of the Medicare benefit period.


Q:  Will you still be able to readmit to SNF LOC within 30 days if indicated and if so where will that fall on the variable rates scale? Would it start over or pick back up on day 19 or whatever day they used with the previous stay?

A:  Yes, the PDPM does not change regulation related to readmitting a person for Medicare skilled coverage during the 30-day readmission period.  The variable per diem would reset when a new 5-day assessment is completed.


Q: I was wondering, do 14 and 30-day MDS assessments go away completely, or do they just not factor into PDPM moving forward?

A:  They will go away completely.  They will no longer be an option on the MDS.


Q: To clarify, only the NTA gets the 3x adjustment for the first 3 days? I have seen information indicating it is for all components, and also information indicating it is for only the NTA component.

A:  The 3x adjustment for the first 3 days applies ONLY to the NTA component.


Q: Does the 5-day ARD have grace days?

A: The rules for completing the 5-day are not changing. The ARD would still be anywhere from days 1 – 8.


Q: Presumption of coverage under PDPM: does that mean that they have to meet 1 in each NSG, PT/OT, SLP, and NTA OR just meet 1 of those components?

A: To qualify for the Presumption of Coverage under PDPM, the resident must meet only 1 of the following 4 qualifiers:

  1. Assigned to a nursing group in the Extensive Services, Special Care High, Special Care Low, or Clinically Complex categories; or
  2. Assigned to one of the following PT/OT groups: TA, TB, TC, TD, TE, TF, TG ,TJ,TK, TN, and TO; or
  3. Assigned to one of the following SLP groups: SC, SE, SF, SH, SI, SJ, SK, and SL; or
  4. The NTA component uppermost (12+) comorbidity group.


Q: Will managed care assessment be done as a 5-day separate assessment that is not transmitted and we do Admission only on those?

A:  At this time CMS has not issued any change in policy related to submission of PPS assessments.  PPS assessments (5-day) completed under PDPM for non-Medicare beneficiaries should not be submitted unless otherwise directed in the future by CMS. It is advised to continue to separate the 5-day from the OBRA Admission assessment unless otherwise instructed.


Q: The 2% reduction in therapy- is it designed to keep stays short?

A:  CMS analysis indicates that therapy services decreases during a Medicare stay.  The 2% reduction is implemented to correspond with this reduction of services.


Q: We provide trach and vent care in Skilled Nursing Facilities. Most of our patients are Medicaid. How might this impact us?

A:  This would be a state specific question and depends on your specific state’s reimbursement system and what plans once PDPM is implemented.  Medicaid specific questions will need to be addressed directly to the respective state.

There may be no immediate impact as CMS will continue to support the RUG III/RUG-IV systems until further notice.  Also, an Optional State Assessment (OSA) will be implemented with the PDPM for states that require additional assessments.


Q: Will therapy still need to track and report co-treatment minutes on the MDS?

A:  Yes, the MDS will still have separate entries for individual, group, concurrent, and co-treatments.


Q: We often receive transfers from other LTC facilities wishing to admit to our facility. We would be doing a 5 day for our facility. The other facility already received the variable per diem rate adjustment. Does that preclude us from receiving the base rate adjustment? Or would we still be able to utilize the base rate adjustment?

A:  The variable rate adjustments are based on Medicare stays. Since the resident would be new to your facility, this is considered a new Medicare Part A stay, requiring a new 5-day assessment. The variable rate adjustments would be reset to day 1.


Q: Are MD certs required for 5-14-30-60-90 still or just for the 5 day?

A: SNF Physician certification and recertification regulatory requirements are independent of the current RUG payment system and the upcoming PDPM.  Physician certifications would still be required upon admission. Recertifications would still be required by day 14 and no later than every 30 days thereafter.


Q: What if a patient misses 3 days of therapy in a row? Will we have to do another MDS?

A:  No assessment would be required.  The PDPM is not based on the amount or frequency of therapy services.



For additional information, check out the top questions asked for our entire PDPM webinar series.

As the focus shifts from therapy resource utilization to one of clinical characteristics and conditions, it will be important for SNF providers to receive accurate and up-to-date information related to this system. Our six part PDPM webinar series is designed with your concerns in mind. You can view the entire PDPM Webinar Series on demand today.


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