BACKGROUND

On October 1, 2019, skilled nursing facility (SNF) providers will submit claims for Medicare Part A services under an entirely new per-diem SNF prospective payment system (PPS) model called the Patient Driven Payment Model (PDPM).  Payments under the RUG-IV SNF PPS model will end on September 30, 2019.

The PDPM case-mix payment model relies on resident clinical characteristics reported on the minimum data set resident assessment instrument (MDS-RAI) and claim form and includes significant changes in the assessment process and schedules, clinical information used to determine case-mix payment rates, and how therapy services are reported.  These changes will impact all aspects of SNF operations including front office, billing, resident assessment, and care planning and delivery processes.  These changes will also interact with other SNF policies that are not changing including:

• Need for Daily Skilled Care
• Requirements of Participation and Related Survey & Certification
• SNF Quality Programs (SNF QRP and SNF VBP)
• Annual Payment Rate Update
• Consolidated Billing

The PDPM payment model may also interact with other payers that rely on RUG-based payment methodologies including; Medicaid, Medicare Advantage, and the VA, as well as other alternative payment models and demonstrations including ACOs and bundled payments.

The Centers for Medicare and Medicaid Services (CMS) this week issued three important manual updates for PDPM implementation. 

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