Tick, Tock…PDPM is Fast Approaching!

The Medicare payment classification system change to Patient Driven Payment Model (PDPM) for SNFs is October 1, 2019. Medicare payments will be based on the PDPM classification system instead of the RUGS IV classification system.

There will be no transition period to PDPM. Nursing facilities need to perfect their systems that impact PDPM now. Help your team prepare with the following 90-day plan:

Click to download tool>

July 2019: Educate and Review

  • Complete staff education about the PDPM classification system and ICD10 CM Official Coding Guidelines for admissions staff, billing staff, MDS staff, social workers, nurse leaders, HIM staff, Case management staff and Administrative staff.
  • Review Medicare technical and clinical coverage criteria, as they have not changed.
  • List changes to make to standard clinical document:
    • Update the pre-admission intake forms to collect primary diagnosis and other co-morbidities.
    • Identify a PDPM estimator for use with pre-admission reviews.
    • Update discipline-specific Admission assessments to refer to the clinical conditions used in the PDPM classification system.
    • Update daily skilled nursing charting format to refer to the clinical conditions used in the PDPM classification system.
    • Revise the Medicare meeting agenda to review the skilled residents’ progress toward goals related to their clinical conditions.

August 2019: Identify and Revise

  • Determine changes needed to the E.H.R. care plan library to capture the monitoring and treatment provided for residents’ clinical conditions.
  • Review Medicare Advantage contracts to validate payment structures and confirm the internal processes for calculating RUG categories, if relevant for Medicare Advantage plan billing.
  • Identify the mechanisms to monitor and decide about completing an Interim Payment Assessment.
  • Write and revise policies and procedures for managing the PDPM system:
    • Interim Payment Assessment criteria and process
    • Use of the Other State Assessment item set
  • Review and revise as needed, the assignments of MDS section completion (e.g., Section I, Section K, and Section O).
  • Review diagnosis codes and sequencing for Medicare Part A stays.

September 2019: Monitor and Implement

  • Begin to estimate PDPM payments for new Medicare Part A admissions.
  • Monitor the number of Medicare Part A admissions to plan for transition IPA scheduling.
  • On September 25, identify the residents expected to still be in the facility on October 1, 2019. Review their diagnosis codes and sequencing. Review Section GG coding and each resident’s current status.
  • On September 28, schedule Interim IPA assessments with ARD between October 1 and October 8.

Click here to download and print the complementary tool.

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