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Your PDPM Questions Answered – Part 6: Putting It All Together

In the final Part 6: Putting It All Together 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.

Your Questions From Our PDPM Webinar Series Recap


Q: If someone is admitted on 9/28 you will do a 5 day for RUGs; then an IPA. Will the 9/28 RUGs assessment be 10/4? Then IPA first 7 days of October?

A: The PPS 5-day RUG assessment will have to have an ARD of 9/28 – 9/30. This will generate the RUG HIPPS code to bill for 9/28 – 9/30. Then the IPA assessment will need to have an ARD of 10/1 – 10/7. This will generate the PDPM HIPPS code to begin billing as of 10/1/19.


Q: The ARD for any PPS RUGS IV has to be 9/30 or earlier. Correct?

A:  That is correct.


Q: Can a RTP diagnosis still be used, but just not as a primary?

A:  Yes, the ‘return to provider” codes only relate to using these codes as the primary diagnosis in I0020B.  These codes are still valid codes and can be used as secondary codes when applicable.


Q: How will it reflect that MED A is ending prior to 100th day or therapy is pulling out but nursing will continue to skill a resident?

A: There is no requirement to conduct any assessment. Payment does not change under the PDPM when therapy discontinues and skilled coverage continues for nursing services.


Q: What if we have a resident who is at day 89 at the end of September? We did a 90 Day for end of September and an IPA for 10/3. That supposedly resets to day 1. Do they have another 100 days with PDPM??

A: The Medicare days do not reset as of 10/1.  10/1 will be considered day 1 for the variable per diem adjustment schedule. The resident would still only have 11 days of Medicare left.


Q: Some trainers are saying that we shouldn’t be using the Z code, but the reason why the amputation was needed?

A: Z codes may be used when appropriate and may make a difference on the PDPM HIPPS code.


Q: Some trainers have said that if errors are found on the 5th day PDPM MDS and we need to make modifications, that the payment cannot be adjusted based on the modified MDS – true or false?

A: Per the CMS PDPM FAQ (4/17/19): All rules applied to assessment modifications and submissions will remain the same as they currently are.


Q: For clarification, you still do the OBRA discharge if they are gone >24 hrs and then a re-entry, but it doesn’t change your PDPM assessments if they are not out 3 nights?

A:  That is correct – that would be considered an “interrupted stay,” which is treated as a continued Medicare stay and not a new Medicare stay. Rules for completion of OBRA discharge assessments and Entry Tracking records are not changing with the implementation of PDPM.


Q: If the BIMS was not completed in the lookback period, and is dashed on the MDS, how will a SLP score be generated?

A: Per the CMS PDPM FAQ (4/17/19):  In order to receive a PDPM classification, all required items must be completed.  Either a BIMS score or CPS score (staff assessment) is necessary to classify the patient under the SLP component.  If neither the BIMS nor the staff assessment is completed, then the patient will not be classified under PDPM and a PDPM HIPPS code will not be produced for this assessment.

In addition to the above, the DRAFT MDS 3.0 manual provided the following additional guidance:

Only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable resident when the resident is unexpectedly discharged from a Part A stay prior to completion of the BIMS.


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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