While a SNF’s decision to complete the IPA itself is optional, they must remain fully aware of any changes in a resident’s condition.
The Interim Payment Assessment (IPA) is an optional assessment that may be completed to capture changes in a resident’s status and condition and to report a change in a patient’s PDPM classification. Providers determine when to complete an IPA, which may be any time after an initial/5-day assessment is completed. This “open-ended” guidance leaves facilities with the responsibility of developing a framework for clinical analysis and decision making regarding when to complete an IPA.
CMS has clarified that the SNF’s responsibility includes recognizing those situations that warrant a decision to complete an IPA in order to account appropriately for a change in patient status. Furthermore, CMS notes that while a SNF’s decision to complete the IPA itself is indeed optional, the SNF’s underlying responsibility to remain fully aware of (and respond appropriately to) any changes in a resident’s condition is in no way discretionary.
Strategies for Providers
- Providers should have solid processes in place to identify and monitor changes in resident condition or PDPM classification. Just as the different PDPM criteria are the basis for initial patient classification, changes or occurrences of these same criteria should be considered for IPA completion.
- A policy referencing CMS guidance should be developed to establish clinical criteria for triggering IPAs. Consider including the following elements in your policy and procedure:
- When to complete the optional IPA
- What criteria should be used for the Interdisciplinary Team (IDT) to decide when an IPA is appropriate
- Assessment Reference Date (ARD), completion and submission timeframes
- Clinical and PPS meetings are beneficial to recognize changes in condition that may occur on a daily basis. An IPA Checklist can assist providers in tracking changes specific to the Part A resident that should be considered.
- The IDT should continuously monitor changes in functional status for Section GG, which is included in the IPA to calculate the PT, OT and Nursing components. The IPA assessment period for Section GG includes the ARD of the IPA and the two previous days.
Payment established from the IPA begins on the ARD, so prompt identification of resident changes and awareness of look-back/assessment periods is important for reimbursement. Each day that a change impacting reimbursement has not been communicated may result in lost dollars from the time of the occurrence until the ARD of the IPA. Keep in mind that there are many moving parts under PDPM and that a clinical change that may increase reimbursement in one component may be negated by changes in other components (e.g. the function score).
Examples of clinical changes that may prompt completion of the IPA:
- Change in BIMS score
- New orders (i.e., isolation, IV fluids or medications, respiratory therapy)
- Occurrence of swallowing disorder
- Changes that impact the GG function score
- New diagnosis (i.e. septicemia or pneumonia)
Consider this: For a resident admitted with clinical services such as IV medications that have subsequently been discontinued, completion of an IPA will likely reflect a lower acuity with a lower case-mix index for the nursing AND NTA components for the remaining Medicare stay. In contrast, If a cognitive impairment, neurological disease, swallowing problem or mechanically altered diet was not coded on the initial MDS assessment, completing an IPA and reporting these conditions may improve reimbursement for the SLP component and overall per diem. If a resident’s function score improves or declines, providers may want to consider performing an IPA, due to the potential impact on the PT, OT, and/or Nursing components. With so many contributing factors, providers should evaluate the condition change(s) for effects on each of the five PDPM components including PT & OT, SLP, Nursing and NTA components before completing an IPA.
Additionally, choosing to complete an IPA (or not) does not eliminate or replace the provider’s responsibility to assess the resident for completion of the OBRA Significant Change in Status Assessment (SCSA). Under RUG-IV, completion of the SCSA would change the per diem rate based on the established RUG. This is NOT the case with PDPM as the SCSA no longer has an impact on payment. Providers are encouraged to assess for and consider completion of the IPA and/or SCSA when changes in condition are identified, keeping in mind that these assessments cannot be combined. The criteria and guidance for the SCSA can be found in the RAI 3.0 User’s Manual.
References:
https://www.govinfo.gov/content/pkg/FR-2019-08-07/pdf/2019-16485.pdf
https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM
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IPA Toolkit
This tool-kit is intended to assist facilities by providing resources including a Policy Template, Clinical Meeting Checklist, and GG Documentation Tool to streamline clinical data collection and assist with IDT collaboration related to the optional Interim Payment Assessment (IPA) under PDPM. Click here to learn about this toolkit.
Identifying Changes in Condition Competency Toolkit
This Tool-kit includes Power Point Slides and a Lesson Plan/Instructor Guide for lecture purposes. This kit also includes 3 Case Studies with Instructor Guidance, Case Study worksheets for participants, a Return to Hospital Review tool, and a “Take Away” handout for participants. Competency can be evaluated through the use of the included pre- and post-tests and the Competency Evaluation form. Click here to learn about this toolkit.
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Blog by Kristen Walden, MSN, RN RAC-CT, Clinical Consultant, Proactive Medical Review
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