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Your PDPM Questions Answered – Part 3: Nursing Case Mix Groups

In Part 3: Nursing Case Mix Groups, of our PDPM 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 on PDPM’s Nursing Case Mix Groups

Q: It’s my understanding we need to Restorative started no later than day 2 so we can have the 6 days of Restorative in before day 8. Is that correct?

A: Yes, that would be correct.  In order to qualify for the restorative component (end split) there must be at least 6 days of restorative provided.


Q: What is section G being used for in PDPM?

A: Section G will not be used in the PDPM.  The PT/OT and  Nursing Function Scores (similar to the ADL score) will be calculated based on coding of specific items in Section GG.


Q: Are IV medications considered extensive services?

A: IV medications provided while a resident of the SNF qualify for Clinically Complex under the PDPM.  This is no different than the current RUG-IV criteria.


Q: If resident discharged from therapy, is this considered a significant change that we need to complete an Optional State Assessment (OSA)?

A: Under PDPM, there is no requirement to complete an OSA if all therapies are discontinued.  An OSA is an “Optional State Assessment” so would have to inquire with the State on what, if any requirements they would have related to this assessment.

Also, OBRA regulations related to completion of a SCSA still apply, so it may be possible that the person may qualify for a SCSA improvement.


Q: Do you know how the insurance payments will be based on? Will it follow the same PDPM?

A: Questions related to insurance plans other than traditional Medicare need to be addressed with the plan specifically.


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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