What are some tips to determine if the completion of the optional Interim Payment Assessment (IPA) is appropriate to impact reimbursement?



The IPA may be completed when a Medicare Part A beneficiary’s condition and/or the care and services provided change such that the current rate of reimbursement is lower than the rate supported by the timely completion of an IPA.

The Medicare 5-day MDS establishes the payment rate for the entire Part A stay unless an IPA is completed. When an IPA is completed the newly established rate of reimbursement becomes effective on the ARD. Timely identification of circumstances that warrant the completion of an IPA is critical to ensure accurate reimbursement.

The MDS team should utilize information obtained from the facility’s 24-hour report, daily clinical meetings, and weekly Medicare meetings to determine whether the completion of an IPA is appropriate. If an IPA is warranted, next steps include establishing the ARD and notifying the team of the need to complete the BIMS and PHQ-9 interviews and Interim GG functional assessments.

Some key indicators that an IPA may be appropriate include, but are not limited to:

      • Resident returns to the facility after an ED visit or interrupted stay: The focus of the review should include any new diagnoses that may impact the nursing, NTA and/or SLP Case Mix Groups (CMG). In addition, review acute care records for the administration of IV fluids for nutrition or hydration that will classify the resident into the Special Care High nursing CMG. This will positively impact the nursing component of the rate if the current nursing CMG is lower in the hierarchy.
      • Any residents newly placed in isolation for an active infection that meets the criteria for MDS coding as outlined in the RAI User’s Manual. This service impacts both the nursing and NTA CMGs.
      • Any resident newly started on IV medications (5 NTA points)
      • A new skin condition, such as a pressure ulcer, with associated treatment
      • New use of oxygen
      • A new swallowing issue documented and/or a diet change to mechanically altered
      • Decline in cognition in a patient who was cognitively intact (5 day MDS BIMs 15-13)
      • An increase in mood indicators (mood interview)
      • Significant changes in self-care or mobility that may impact the PT/OT/Nursing GG function scores

The MDS coordinator and other key IDT members should have a thorough understanding of the components of the PDPM payment model. Like any other assessment, the IPA captures the clinical characteristic of the resident during a specific timeframe or observation period. Therefore, care should be taken to review all components of PDPM during this snapshot in time. While certain data elements may increase reimbursement in one component, certain care and services that were reported on the 5-Day assessment may not still be applicable and cause a decrease in reimbursement in other components. The IPA is optional and completed at the discretion of the IDT.

Visit the Proactive Shop – Proactive LTC Consulting (proactiveltcexperts.com) for training opportunities and products to support PDPM success.

Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant

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