What does PDPM mean for Medicare Part A beneficiaries who will reside in the facility under both payment models?

RUG-IV comes to a hard stop at 11:59pm on September 30th, 2019 and will be replaced with the Patient Driven Payment Model at 12:00am on October 1st. What does this mean for Medicare Part A beneficiaries who will reside in the facility under both payment models?

Traditional Medicare residents admitted prior to 10/01/19 will be reimbursed for services provided through September 30th using the RUG-IV payment model. This means all currently required PPS assessments need to be completed as outlined in the RAI v 1.16. Depending on the resident’s actual date of admission and how many Medicare covered days have been used as of September 30th, you may need to ensure completion of the 5-day, 14-day, 30-day, 60-day, 90-day, and/or SOT, EOT, and COT as needed for the individual resident. Therefore, an important first step for a smooth transition will be reviewing length of stay and PPS assessment scheduling to fulfill RUG-IV assessment requirements for September billing.

What about October billing? Since RUG-IV HIPPS codes will no longer be valid, a new assessment is needed to generate a PDPM HIPPS code for October billing and beyond. This is where the Transitional Interim Payment Assessment (IPA) comes into play.

For Medicare Part A beneficiaries who admit on or after 10/01/19, an Initial Medicare Assessment (aka 5-day) will be completed and the IPA will be completely optional after that point. However, for residents spanning both payment models, the transitional IPA is required. The transitional IPA must be scheduled with an assessment reference date (ARD) somewhere between 10/01/19 and 10/07/19 (see below table), and within the resident’s benefit period. For example, if a resident is set to exhaust Part A services on 10/04/19, the transitional IPA ARD must be scheduled between 10/01/19 and 10/04/19. Once the ARD is scheduled, providers will still have a 14-day completion period.

For purposes of the transitional IPA, PDPM payment and the variable per diem adjustment schedule will begin on 10/01/19 regardless of the ARD date. This means providers will receive the 3.0 multiplier for the established NTA rate for 10/01, 10/02, and 10/03 so appropriate recognition and reporting of NTA services and conditions will be important.

Other considerations for accurate and timely data collection include assessment of Section GG performance items and resident interviews. Depending on the ARD selected for the transitional IPA, the look-back period for some items may extend into September. With an ARD of 10/01/19 for example, the Section GG assessment period would include 9/29, 9/30, and 10/1. Communication to the team regarding the selected ARD for each individual resident will also be important in terms of completing the resident interviews according to RAI guidelines, preferably on or one day before the ARD. For this reason, it is imperative that time is well spent in the assessment scheduling and planning phase to avoid confusion and limit MDS coding errors.

Each Medicare Part A beneficiary must have a transitional IPA completed for PDPM

Each Medicare Part A beneficiary who admitted to the facility prior to 10/01/19 and will remain in the facility under Medicare Part A services on 10/01/19 must have a transitional IPA completed for PDPM. Things to consider:

  • Transitional IPA required; if completed late, penalties applied
  • ARD must be scheduled between 10/01/19 and 10/07/19 -and- within the resident’s benefit period
  • Section GG Interim Performance will need to be assessed
  • BIMS and PHQ-9 will need to be conducted
  • IPA cannot be combined with any other assessment
  • Consider staggering ARDs for work flow management as needed
  • Keeping in mind that you have 14-day completion period from the ARD (A2300)

Scheduling the transitional IPA ARD

Have questions? Contact us to learn how we can help with your PDPM transition.

PDPM Skilled Nursing Charting Guidelines

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Webinar: PDPM Skilled Nursing Supportive Documentation for Skilled Level of Care

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Blog by Eleisha Wilkes, RN, RAC-CT, Clinical Consultant, Proactive Medical Review

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