PDPM Basics
PDPM Overview
Patient-Driven Payment Model (PDPM) The Patient-Driven Payment Model (PDPM) is a Medicare payment system implemented by the Centers for Medicare & Medicaid Services (CMS) on October 1, 2019. PDPM represents a shift from the previous payment model. PDPM focuses on the specific clinical needs and characteristics of the patients, aiming to more accurately reimburse SNFs based on the complexity and acuity of the care required.
Why PDPM Matters!
PDPM emphasizes accurate clinical assessment and appropriate care planning, making it crucial for facilities to understand and implement these changes effectively.
Key Components: ADDITIONAL TRAINING OR EDUCATIONAL INFORMATION CAN BE FOUNDHERE
Clinical Categories Under PDPM
Under PDPM, patients are classified into one of ten clinical categories based on their primary diagnosis and comorbidities. This classification determines the patient's care needs and reimbursement rates.
Functional Score
The Functional Score evaluates the patient's abilities in daily activities, assessing the level of assistance required.
Under PDPM, patients are classified into one of ten clinical categories based on their primary diagnosis and comorbidities. This classification determines the patient's care needs and reimbursement rates.
- Primary Diagnosis: The primary reason for the patient’s admission to the facility influences the clinical category.
- Comorbidities: Secondary conditions that impact the patient’s overall health and care requirements.
- Major Joint Replacement or Spinal Surgery
- Non-Orthopedic Surgery and Acute Neurologic
- Acute Infections
- Cardiovascular and Pulmonary
- Cancer
- Other Medical Conditions and Diagnoses
Functional Score
The Functional Score evaluates the patient's abilities in daily activities, assessing the level of assistance required.
Assessment Areas:
- Mobility: Includes bed mobility, transfer capabilities, and ambulation.
- Self-Care: Encompasses eating, toileting, and personal hygiene.
- Cognitive Function: Assesses memory and decision-making capabilities.
Example: A patient who requires moderate assistance with eating but is independent in toileting will have a lower functional score compared to a patient who is dependent in multiple areas, leading to adjusted resource allocation and reimbursement.
Nursing Component
The Nursing Component considers various patient characteristics to assess their overall nursing needs, including clinical complexity and daily care requirements.
Nursing Component
The Nursing Component considers various patient characteristics to assess their overall nursing needs, including clinical complexity and daily care requirements.
Patient Characteristics:
- Behavioral Symptoms: Frequency and severity of behavioral issues.
- Clinical Conditions: Presence of conditions like diabetes, chronic obstructive pulmonary disease (COPD), or infections.
- Skilled Nursing Needs: Requirements for wound care, respiratory therapy, or IV medications.
Example: A patient with multiple pressure ulcers requiring extensive wound care will have a higher nursing component score than a patient with stable diabetes, reflecting the additional resources needed for their care.
Coding of the MDS
The Minimum Data Set (MDS) is a comprehensive assessment tool used in long-term care facilities to assess the care needs of residents. Proper coding of the MDS is crucial for accurate classification under PDPM.
Coding of the MDS
The Minimum Data Set (MDS) is a comprehensive assessment tool used in long-term care facilities to assess the care needs of residents. Proper coding of the MDS is crucial for accurate classification under PDPM.
Primary Diagnosis: Accurate coding of the primary diagnosis is essential as it determines the clinical category under PDPM.
Example: If a patient is admitted for rehabilitation after a stroke, the primary diagnosis should reflect the stroke, placing the patient in the "Non-Orthopedic Surgery and Acute Neurologic" category.
Secondary Diagnoses and Comorbidities: Secondary conditions and comorbidities also need to be accurately coded as they impact reimbursement and care planning.
Example: A patient with diabetes as a secondary diagnosis may require additional monitoring and care, influencing the overall care plan.
Section GG: This section assesses functional abilities and goals, which influence the functional score used in PDPM.
Example: Accurate coding of a patient's ability to transfer or walk will affect the functional score and subsequently the reimbursement rate.
NTA Points
Non-Therapy Ancillary (NTA) points are used to determine the level of non-therapy ancillary services required by a patient. Accurate assessment and coding of certain conditions and comorbidities are essential to capture the correct NTA score.
NTA Points
Non-Therapy Ancillary (NTA) points are used to determine the level of non-therapy ancillary services required by a patient. Accurate assessment and coding of certain conditions and comorbidities are essential to capture the correct NTA score.
NTA Comorbidities: Certain comorbidities and conditions contribute to the NTA score.
Example: Conditions such as HIV/AIDS, IV medication, and certain infections have high NTA points.
Calculation of NTA Points: NTA points are accumulated based on the presence of specific comorbidities.
Example: A patient with diabetes, COPD, and receiving IV medications will have a higher NTA score, reflecting the increased resource utilization.
Setting ARD Dates for the PPS Assessment (5-Day) and Its Importance
The Assessment Reference Date (ARD) is the specific date set for the completion of the MDS assessment. The ARD determines the observation (look-back) period for the assessment and is crucial for accurate data collection and subsequent reimbursement. Setting the ARD so that capturing hospital activity is important!
Setting ARD Dates for the PPS Assessment (5-Day) and Its Importance
The Assessment Reference Date (ARD) is the specific date set for the completion of the MDS assessment. The ARD determines the observation (look-back) period for the assessment and is crucial for accurate data collection and subsequent reimbursement. Setting the ARD so that capturing hospital activity is important!
Importance of ARD: The ARD impacts the accuracy of the MDS assessment and the resulting reimbursement and establishes the look-back period for all items.
Example: An incorrect ARD can lead to inaccurate assessment of the patient's condition and needs, resulting in incorrect reimbursement rates.
Setting the ARD: The ARD should be set considering the patient's admission date, hospital information and clinical diagnosis and clinical changes.
Example: If a patient received IV hydration or nutrition while in the hospital, it could impact the facilities Nursing Category on the PPS assessment. The lookback on this item is seven days - so setting your ARD on day 7 or 8 prevents you from including this crucial data on your assessment. MDS must ensure the ARD captures all the complexities of the patient.
For your consideration:
Clinical Category Example: A patient admitted for rehabilitation following a hip replacement would fall under the "Major Joint Replacement or Spinal Surgery" category, leading to specific reimbursement rates reflecting the intensive therapy needs associated with their recovery.
Clinical Category Example: A patient admitted for rehabilitation following a hip replacement would fall under the "Major Joint Replacement or Spinal Surgery" category, leading to specific reimbursement rates reflecting the intensive therapy needs associated with their recovery.
Functional Score Example: A patient who requires moderate assistance with eating but is independent in toileting will have a lower functional score compared to a patient who is dependent in multiple areas, leading to adjusted resource allocation and reimbursement.
NTA Points Example: A patient with HIV/AIDS, requiring IV antibiotics, and suffering from a major depressive disorder would accumulate several NTA points, reflecting the high level of ancillary services required.
Setting ARD Example: For a patient admitted on June 1st, setting the ARD for June 8th ensures that the initial assessment captures the patient's baseline condition accurately, facilitating appropriate care planning and reimbursement. Proper coding, accurate calculation of NTA points, and correct setting of ARD dates are essential elements under PDPM to ensure that the patient's care needs are appropriately classified and reimbursed, ultimately improving the quality of care provided.