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Are You Ready? PDPM is on the Horizon

PDPM will become effective in a little more than three weeks, on October 1, 2019. Is your team ready for this substantial change?

Below are a few leadership considerations as providers transition to this new payment model:

1. Identify the Medicare coverage criteria are met throughout the Resident’s Stay.

Providers can no longer rely upon the RUGs categories as a guide in determining the Medicare coverage criteria met by the resident’s stay. The Centers for Medicare and Medicaid Services (CMS) has provided information surrounding PDPM components that meet the Administrative Presumption of Coverage rules in the recently released Fact Sheet. The Administrative Presumption of Coverage is effective until the Assessment Reference Date (ARD) of the first Medicare MDS. Learn more: Download the Fact Sheet.

Because most Medicare stays have been billed at Rehab RUGS categories, providers are not accustomed to thinking about all five of the Medicare Clinical Coverage Criteria (Skilled Rehab, Skilled Nursing, Assessment and Observation, Management of a Plan of Care and Teaching and Training). Consider the following:

  • Identify ALL of the clinical coverage criteria met at admission.
  • Review that coverage criteria met at each weekly Medicare meeting.
  • When a resident’s stay no longer meets any coverage criteria, issue a beneficiary notice of non-coverage.
  • The clinical coverage criteria are described in detail in the Medicare Benefit Policy Manual, Chapter 8. Review by clicking here.

2. Understand the ICD 10-CM Official Coding Guidelines.

The entire interdisciplinary team (IDT) needs to have a working knowledge of the coding guidelines to understand the selection of the Primary Diagnosis, which impacts three of the five case-mix adjusted PDPM components. Download the 2020 ICD 10-CM Official Coding Guidelines.

There are specific diagnosis codes that are allowed for Speech-Language Pathology (SLP) co-morbidities and Non-therapy Ancillary (NTA) items.

Download information CMS published regarding the diagnosis code mapping for Clinical Condition Categories, SLP co-morbidities, and NTA.

3. Identify the Primary Diagnosis and Co-Morbidities.

The most effective identification of the Primary Diagnosis is made through collaboration by the IDT. It is possible that more than one condition treated in the proximal hospital stay will meet the definition from the Official Coding Guidelines for Primary Diagnosis. The IDT can discuss the reason for the resident’s Medicare stay and agree upon the appropriate Primary Diagnosis. The Primary Diagnosis and active co-morbid conditions should be integrated into admission assessments, care plans, and daily skilled charting to support Medicare billing. There are definitions for these terms in the Official Coding Guidelines.

4. Understand the new Interrupted Stay Policy.

With the implementation of the PDPM classification system, CMS will also implement a new Interrupted Stay policy. Under this policy, a resident who ends their Medicare stay, either by a non-coverage notice or by discharging from the SNF, and resumes care in the same SNF before midnight of the third non-covered day, will restart their stay where they left Medicare coverage. Read the below examples:

  • If a resident is admitted to the SNF, goes to the hospital on Day 3 for two midnights, and returns to the SNF before midnight of the third day, the resident will have a continuation of the prior Medicare stay. There will not be a new 5-day MDS completed, and the Variable Per Diem Adjustment calendar continues from Day 5.
  • If a resident is admitted to the SNF and goes to the hospital on Day 3 for four midnights, and returns to the SNF on Day 5, this will be a new Medicare stay upon return. A new 5-day MDS will be completed after re-entry and the Variable Per Diem Adjustment calendar will reset to Day 1.

CMS provided clarification of the Interrupted Stay Policy in a revised Fact Sheet. Download the Fact Sheet from CMS


PDPM Insight, Expertise and Knowledge.

Pathway Health PDPM experts can assess your organization’s readiness and provide a detailed action plan for enhancing or improving these processes. Our PDPM consulting services and tools can support your busy leaders and staff to effect a smooth transition to the PDPM system. Pathway Health also offers expert PDPM training – classroom, onsite and web-based.

Contact us to learn more.

Karolee Alexander
Director of Reimbursement and Clinical Consulting