By Glenda Beasley RN, RAC-CTA
The Patient-Driven Payment Model (PDPM) was implemented in October 2019, bringing significant changes to the skilled nursing facility reimbursement system. Among these changes is the optional Interim Payment Assessment (IPA). Despite being five years into PDPM, questions about when to complete an IPA persist. The decision is left to the facility's team, which varies by facility. The essential question remains: does the 5-day PPS MDS completed on admission accurately capture the resident's current clinical picture, or is an updated assessment necessary?
Key IPA Considerations
General IPA Guidelines
- Timing: An IPA cannot be completed before the 5-day PPS Assessment.
- Unscheduled Assessment: The IPA is an unscheduled assessment, decided by the Interdisciplinary Team (IDT) based on facility practices.
- Clinical Changes: The IPA can capture significant clinical changes in the resident’s status.
- Completion Timeline: It must be completed within 14 days after the Assessment Reference Date (ARD + 14).
- Stand-Alone Assessment: The IPA should not be combined with other assessments.
The payment adjustment begins on the ARD of the IPA and continues throughout the resident's Part A stay unless another IPA is completed or the resident is discharged. Importantly, the Variable Per Diem (VBP) is not affected by the IPA.
Payment Implications
“The IPA does not affect the variable per diem. When an IPA is completed and payment changes, it continues the variable per diem schedule established by the 5-day assessment.”
Assessing the Need for an IPA
When determining the necessity of an IPA, compare it to another PPS assessment (e.g., a 5-day or another IPA). Key considerations include:
- Clinical Category: Is the primary diagnosis still triggering the initial clinical category, or has there been a change?
- Clinical Changes: Has the resident experienced significant clinical changes, such as an infection requiring isolation?
- New Services: Is the resident now receiving a new skilled service, such as IV medications or fluids for hydration?
- Cognitive Status: Has the resident’s cognitive status changed since the prior assessment?
- Swallowing Issues: Are there new or worsening swallowing issues?
- Functional Score: Consider changes in the resident's functional score and the corresponding impact.
The IPA will reflect section GG items for PT, OT, and the Nursing Component, with a new column 5 capturing the resident's performance. While not exhaustive, these considerations should guide your decision-making regarding the IPA.
Tips for Tracking IPA Decisions
Interdisciplinary Meetings
Interdisciplinary meetings, often called “Triple Check” or “Medicare” meetings, are crucial for tracking IPA decisions throughout the stay of a Med A resident.
- Knowledgeable Team Members: Ensure team members understand what an IPA is and can trigger its completion if needed. Training might be necessary for team members to identify appropriate times for an IPA.
- Tracking Decisions: Develop a system to document the decision-making process for IPAs. This documentation can help recall the rationale if questioned by an external reviewer. Minutes or notes from interdisciplinary meetings discussing Med A residents should include these reasons.
- Systematic Review: Establish a systematic approach to review key areas affecting IPA decisions.
- Routine Review: Include IPA discussions in your facility’s QAPI/QAA meetings for routine review.
By understanding the optional IPA and implementing systematic approaches for its decision-making and documentation, facilities can better navigate PDPM and ensure accurate reimbursement based on the resident's clinical picture.