The Patient-Driven Payment System, the MDS
v3.0 Assessment Skills
Necessary for Success
Meet your presenter
Reta A. Underwood, RAC-CT, QCP, CPC President
Reta has over 34 years of professional work experience in the long-term care industry. Reta’s experience has included management and director positions with nursing facilities and health care companies. She has also provided corporate-wide MDS support services, numerous mock surveys, regulatory compliance correction, educational programs, clinical documentation, quality assurance programming, and most recently implemented PDPM in facilities nationwide.
Reta has supplied input to CMS and has been included on projects and discussions pertaining to post-acute care. She holds national certifications through the American Association of Nurse Assessment Coordination (AANAC) as a Resident Assessment Coordinator (RAC-CT); Quality (QAPI) Professional and Nurse Manager and as a certified ICD-10-CM coder.
Reta has had numerous articles published in the long-term care industry trade publications and has been used as an expert resource professional for media interviews including McKnight’s News; HCPro MDS and PPS Advisor and Provider AHCA magazine.
Reta has also copyrighted several clinical documentation forms and tools, such as for Medicare Triple Check Process, nutritional assessment, skilled clinical and MDS documentation, and restorative nursing programming.
Legislation
• Balanced Budget Act (BBA) 1997
• Balanced Budget Refinement Act (BBRA) 1999 • Benefit Improvement & Protection Act (BIPA) 2000 • Medicare Modernization Act (MMA) 2003 • Affordable Care Act (ACA) 2010 • Post Acute Transformation Act (IMPACT) 2014
Part A SNF Services Include
NURSING CARE (RN) ROOM AND BOARD PT, OT, AND/OR SLP MEDICAL SOCIAL SERVICES
DRUGS, BIOLOGICALS, SUPPLIES, APPLIANCES AND EQUIPMENT
MEDICAL AND OTHER DIAGNOSTIC OR THERAPEUTIC SERVICES PROVIDED BY A HOSPITAL (AGREEMENT)
OTHER SERVICES NECESSARY TO THE HEALTH OF THE PATIENTS GENERALLY PROVIDED BY SNFS
<IOM 100-2, CH 8, SEC 10>
CHAPTER 6: Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS)
The MDS assessment data is used to calculate the resident’s Patient Driven Payment Model (PDPM) classification necessary for payment. The MDS contains extensive information on the resident’s nursing and therapy needs, ADL status, cognitive status, behavioral problems, and medical diagnoses. This information is used to define PDPM case-mix adjusted groups, within which a hierarchy exists that assigns case-mix weights that capture differences in the relative resources used for treating different types of residents.
The Patient Driven Payment Model (PDPM)
PDPM separately identifies and adjusts for the varied needs and characteristics of a resident’s care and combine this information together to determine payment using 6 separate calculations
Data sources for methodology include Medicare enrollment data, Medicare claims data, MDS assessment data and facility data
Base rates = average cost of treating a typical SNF patient
PDPM
PDPM adjusts payment for each major element of a resident’s SNF care, specifically for physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillaries (NTA). In section 6.6 below, we provide a PDPM calculation worksheet. This calculation worksheet was developed in order to provide clinical staff with a better understanding of how PDPM works. The worksheet translates the standard software code into plain language to assist staff in understanding the logic behind the classification system.
HIPPS Code
First Character: PT/OT Component
HIPPS Code
Second Character: SLP Component
HIPPS Code
Third Character: Nursing Component
HIPPS Code
Third Character: Nursing Component
HIPPS Code
Third Character: Nursing Component
HIPPS Code
Fourth Character: NTA Component
30 - Billing SNF PPS Services
(page 33/104)
SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing data as follows. Refer to the Medicare Claims Processing Manual, Chapter 25, “Completing and Processing the Form CMS-1450 Data Set,” for a description of claim data elements.
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